Does spine or joint surgery really work?what Is the evidence?

October 10, 2017  /  anne brennan

  

Anne Brennan

Updated June 2023.

While surgery can help mild to moderate pain, the evidence suggests a heat pack, massage and carefully progressed, conscientiously done exercise, helped along by pain relief and /or an occasional anti-inflammation medication, is as helpful. If joint or spine pain is severe or prolonged or spreading, surgery can make bad pain worse.

Joint surgery is based on the uproven belief that radiology explains pain by detecting damage in joints, discs, bones or nerves. There is no evidence to support this much loved theory. If your surgeon says there is, please ask for the references and pass them on to me.

X-ray and scans are critical if a recent fracture or a disease is suspected. But they do not help explain pain nor why an ankle or knee ‘gives way.’

Bones and joints are adaptable. Odd looking repairs and damaged/torn/worn bits are normal with ageing or after trauma/ active lives. They might be associated with pain (because most people have pain and most people have worn looking joints) but they have not been proven to cause it. Most over 50s have bulging discs, narrowed disc spaces, ‘bone on bone’ and torn tendons/cartilage. They can be an indication that muscles aren’t up to the job of looking after bones and joints or that posture is poor but they are usually adaptions or repairs and are wrongly blamed for creating ongoing pain. Many people with pain have normal x-rays and many with osteoarthritic x-rays have no pain.

This is not radical thinking : research scientists and medical guidelines have told us this for the last thirty years.

My observation (as a physio who has treated pain for 35 years): surgery can help for a year or two, but unless pain is understood and dealt with effectively, it will pop up again, either in the same spot, OR the matching area on the other side OR on the joint above or below on the same side. It is a quick, sometimes helpful solution to a long term problem that carries risk, especially if repeated. Many who use surgery as a solution rather than carefully progressed exercise and lifetyle changes, end up having several, getting slightly more debilitated each time.

Despite Medical guidelines that recommend exercise NOT surgery for joint pain, many are reluctant to exercise if they think the joint is worn out. This unhelpful belief is not backed by research nor guidelines for the treatment of Osteoarthritis. So where does this beleif come from? I’m sorry to say that, in my experience, most hear it from their medical or health practitioners. I hope this is changing.

Spine Surgery

Research shows that disc surgery to resolve a bulging disc can help some people even if the disc is left bulging AFTER the surgery. Equally it can fail when the bulge is successfully removed. In other words it is 50/ 50 potluck whether surgery does what it is meant to do and whether or not it helps. Other research shows that while spine surgery can relieve some forms of spine pain, the outcome after two years is the same as for those with the same type of pain who undertook exercise rehab instead.

Shoulder surgery

Surgery for shoulder pain or a torn tendon went out of fashion years ago because it didn’t work. It’s back without any new or convincing evidence according to a recent study by Australian researcher, Rachel Buchbinder. It might give some people  some pain relief some of the time but not more than a careful multi modal rehabilitation program.

The shoulder joint is over engineered with back up muscles and tendons so it can cope with 1-2 even 3 muscle tendon tears if muscles are trained or retrained after pain.

Knee surgery


Arthroscopies

This is the only surgery researched using gold standard RCT research. In 1996, J.B. Moseley and his team randomly allocated knee patients to two groups. One group was given   knee arthroscopy   to ‘clean up’ and washout (or lavage) bits of ‘debris’ thought to cause clunking/grinding noises and pain (Osteoarthritis).  The placebo group was given a sham procedure with cuts only (this wouldn’t get past an ethics committee today). The researchers found the real surgery was no better  than the sham group. Other trials back this finding (www.cochranemsk.org)(Felson, 2010; Guild, 2012) (J. B. Moseley et al., 2002)

Despite   overwhelming evidence that arthroscophies don’t work, they are still offered for knee pain (J.B. Moseley, 2003; Potts, Harrast, Harner, Miniaci, & Jones, 2012). Its hard to understand why.

Total knee replacement (TKR) surgery

Research shows that up  to a third of those undergoing TKRs had more problems after surgery than before. Many experience frozen knees. According to the research, frozen knees are not that common but I have seen far too many in Physio. Most will be unable to kneel or ride bikes ever again.

Some surgeons suggest both knees be ‘done’ if x-rays show arthritis even if there is no pain in the second knee. AGAIN: there is no evidence that knee arthritis (or wear and tear), as seen on x-rays, will ever cause pain.

Again there is no clear evidence that knee surgery helps more than a carefully supervised and progressed exercise program. There is evidence that those who undertake surgery becasue they believe it necessary, AND do the post-op exercises will find it helpful. Thisis not the same as saying that it was the best way to allevaite pain. Many say they are happy with their surgery but fail to regain full function. Possibly becue the rehab is arduous. By the time they recover, pain has popped up somewhere else so its back to surgery yet again.

Menisectomy

Arthroscopic partial menisectomies (APMs), have been shown to lead to more knee pain(Hall et al., 2013) (Claes, Hermie, Verdonk, Bellemans, & Verdonk, 2013; Lohmander et al., 2007) unless patients keep up conscientious carefully paced exercise. This suggests it was the exercise not the surgery that helped. Thankfully, I’m seeing less of this unhelpful surgery.

Knee reconstructions.

Sports fans  watch in  horror when their team hero  crumples to the ground clutching their knee. If    scans show torn cruciate ligaments inside the knee   (thought essential for knee stability ), the star is whisked off for   reconstruction surgery. Which seems to work: many return to play after rehab. The question is: was there a better way? 

A Swedish/Danish longitudinal trial (the KANON study) showed that teenagers with torn cruciate ligaments who   exercised instead of surgery did better or as well as those who had surgery five years on (Frobell et al., 2013)(Dunn, Jordan, Mancl, Drangsholt, & Le Resche, 2011) (Culvenor et al., 2013). Those that had knee reconstructions had tight knees which tended to snap again. So surgery is NOT essential to regain stability and reduce pain after a cruciate tear. Don’t copy footballers.

Hip surgery

Total Hip Replacements

Between 7 and 11 percent of Britains have  Total Hip or Knee Replacements (Culliford et al., 2012).  The rate in Australia would be similar. Many swear by their hip surgery. Surgery does help mild to moderate or more recent hip pain but then so do heat packs, carefully paced anti inflammation medication ( 3 days in a row should be adequate) and safe conscientious exercise: i.e. AT LEAST three times a day, gently does it.

Hip Impingement surgery

There is no evidence that congenital (from birth) hip impingement seen on radiology causes pain and, equally, no evidence to show that surgery decreases hip pain more effectively than exercise. It is surprising that teenagers and young adults are still offered this surgery without reasonable evidence.

The question should be asked : while hip or knee surgery may help some, would the majority be equally or better helped, and for longer with less health risks, through a comprehensive, multi modal, personalized program (which includes adequate pain relief and /or perhaps SHORT TERM non-addictive anti inflammation medication that can reproduce the effect of anesthetic/post surgery pain relief ?

At the very least do ALL the post operative exercises (normally prescribed AFTER surgery) but BEFORE surgery , while avoiding actions that trigger sharp or achy pain. And if exercise hurts, find a practitioner who can work out a safe painless exercise entry level that suits you. Exercise should not hurt. The idea that pain is good for you is another unhelpful myth.

A carefully prescribed individual program (not a generic tear off sheet) is critical. Do exercises little and often. Start doing SOOTHING exercises 5 times, 5 times a day spread out over the day. And avoid or modify all aggravating activities. Get exercises updated constantly. And get to a warm hydrotherapy pool every second day for at least two weeks if pain is severe.



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